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Harrisons Cardio Part 2 > Arrhythmias 239 - 251 > Flashcards

Arrhythmias 239 - 251 Flashcards

1
Q

Mechanism of tachyarrhythmias

A
  1. Enhanced automaticity
  2. Triggered arrhythmias (afterdepolarization occuring during phase 3 or 4 or immediately after the action potentials)
  3. Reentry - most common
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2
Q

Acetylcholine

A
  • activates potassium current IkAch the decrease slope of phase 4
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3
Q

Sympathetic

A
  • activates IcaL and If to decrease slope of phase 4
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4
Q

Na channel imp domains

A
  • 3rd and 4th domain: critical to inactivation
  • 6th membrane spanning repeat in the 4th domain: binding site of local anesthetic antiarrhythmics
  • *ca channel drug binding site: alpha 1 subunit
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5
Q

Triggered automaticity 2 types of afterdepolarizations

A
  • early afterdepolarization: occur during the action potential - due to prolonged action potential (hypomagnesemia, hypokalemia, bradycardia, drugs - class 1b/III antiarrhythmics, nonsedating antihistamines)
  • late after depolarizations: after the ap - due to calcium loading (ischemia, digitalis, catecholamines)
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6
Q

Ead associated arrhythmia

A

Torsades des pointes

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7
Q

Sustained reentry requirement

A

Tachycardia wavelength (conduction velocity x refractory period) must fit within the path length (total anatomic length of the circuit)

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8
Q

Region between the head of the activatiom wavefront and the refractory tail

A

Excitable gap

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9
Q

Reentrant arrhythmias with no excitable gap

A

Leading circle reentry

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10
Q

Myocardial gap junctions

A

Connexin 43

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11
Q

Ecg signatures
Wpw syndrome
Arrhythmogenic rv dysplasia
Brugada syndrome

A

Wpw syndrome - delta wave
Arrhythmogenic rv dysplasia - epsilon wave
Brugada syndrome - right precordial st segment abnormality

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12
Q

Relative c/i to head up tilt test

A
  • cad with prox coronary stenosis
  • severe ms
  • lv outflow obstruction
  • severe ms
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13
Q

Vaughan-Williams Classificationnof antiarrhythmics

A

Class I - Na channel inhibitor
1a (open na channels and k channels) (increase action potential duration) - quinidine, disopyramide, procainamide
1b (open and inactivated) (decrease action potential duration) - lidocaine (mi), phenytoin (doc for digoxin toxicity), tocainide, mexiletine
1c (open na channels but dissociate slowly) (no effect action potential duration, prologn qrs) - flecainide, propafenone
Class II - Beta blocker
Class III - K Channel blocker (amiodarone, dofetilide, ibutilide, sotalol)
Class IV - Ca channel blocker (verap, diltiaz)

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14
Q

Cryoablation temp

A

<32degrees

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15
Q

Sa node vs av node

A

Sa: epicardial, Sulcus terminalis, ra-svc junction
Resting membrane potential -40 to -60
Av: subendocardial, apex of the triangle koch (coronary sinus ostia, tendon of todaro, tricuspid annulus)

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16
Q

Sa node dysfunction

A
  1. sinus pause
  2. sinus bradycardia
  3. Tachy- brady variant of sss are at increased risk for thromboembolism and need anticoag
  4. Chronotropic incompetence
    - inability to increase the heart rate to 85% of max predicted for age with max exercise
    - failure to achieve hr >100bpm
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17
Q

SSS1

A
  • AR, SCN5A chromosome 3

- atrial inexcitability syndrome, no p on ecg

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18
Q

SSS2

A
  • AD, HCN4 Gene chromosome 15 (funny channels)

- Tachycardia-bradycardia sick sinus syndrome

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19
Q

SSS3

A
  • associated with variations in MYH6 (myosin heavy chain 6)
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20
Q

Neuromuscular disease + SSS

A
  • Kearns- Sayre syndrome: ophthalmoplegia, pigmentary degeneration of retina, cardiomyopathy
  • myotonic dystrophy
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21
Q

Carotid Sinus hypersensitivity

A
  • pauses >3s in autonomic nervous system testing
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22
Q

Sa node assessment

A
  1. Intrinsic heart rate
    - propanolol 0.2mg/kg and atropine 0.04mg/kg
    - 117.2 - (0.53x age)
    - low ihr =sa node disease
  2. Sinus node recovery time
    - longest pause after overdrive pacing
    - normal <1500ms; corrected for cycle length <500ms
  3. Sinoatrial conduction time
    - 1/2 the difference between instrinsic sinus cycle length and a noncompensatory pause after premature atrial stimulus
    - <125ms
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23
Q

Sa node dysfunction is not associated with increased mortality

A

Sa node dysfunction is not associated with increased mortality

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24
Q

Pacemakers modes and function

A
  1. Chamber paced - 0 none, a atrium, v ventricle, d dual
  2. Chamber sensed - 0 none, a atrium, v ventricle, d dual
  3. Response - 0 none, I inhibition, T triggered, D both
  4. Rate monitoring - r rate responsive (rate sensor: movement, minute ventilation, qt interval)
  5. Antitachycardia function - O none, P antitachycardia pacing, S shock, D pace + shock
    - most common dual: DDDR
    - most common single: VVIR
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25
Q

Twiddler syndrome

A
  • rotation of pacemaker pulse generator

- failure to sense or pace

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26
Q

Pacemaker syndrome

A
  • pacemaker fails to restore av synchrony
  • neck pulsation, fatigue, palpitations, cough, confusion, exertional dyspnea, dizziness, syncope, elevatoon in jugular venous pressure, canon a waves, chf
  • prevention: minimize vetricilular pacing, biventricular pacing
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27
Q

Class I indication for pacemaker in SA node dysfunction

A
  1. Symptomatic sinus brady or sinus pause
  2. Meds with no alternative
  3. Symptomatic chronotropic incompetence
  4. Af in svr and sinus pause >5s
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28
Q

Class IIa indication for pacemaker in SA node dysfunction

A
  1. Hr <40 without clear and consistent association between symptoms and bradycardia
  2. Hr <40 on meds with no alternative with no clear and consistent association between symptoms and bradycardia
  3. Syncope of unknown origin but with sa node dysfunction on provocation testin
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29
Q

Class IIb indication for pacemaker in SA node dysfunction

A
  1. Mildly symptomatic with hr <40
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30
Q

Class III

A
  1. Asymptomatic or symptoms not related to brady (evem if hr <40)
  2. Brady sec to nonessential meds
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31
Q

Types of pacemaker

A

Sa node dysfunction: dual chamber pacing

Carotid sinus hypersensitivity: single chamber pacing

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32
Q

Av blocks anterior vs inferior mi

A

Inferior - more common, av node, stable narrow

Anterior - distal av nodal complex, wide unstable, poorer prognosis

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33
Q

Ah interval

A
  • time from the most rapid deflection of the atrial electrogram in the his bundle recording to the his electrogram
  • represents av node conduction
  • normal <130ms
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34
Q

Hv interval

A
  • time from the his electrogram to earliest onset of qrs
  • conduction thru his purkinje
  • normal <55ms
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35
Q

Class I pacemaker indications in av block

A
  1. 3rd degree - symptomatic, essential drug tx, asystole >3s, escape rhythm <40bpm, post op, catheter ablation associated, neuromuscular d/o associated
  2. Symptomatic 2nd degree
  3. T2 2nd degree wide qrs
  4. Exercised induced 2nd/3rd
  5. Af in svr with pause >5s
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36
Q

Class IIa pacemaker indications in av block

A
  1. Asymptomatic 3rd degree
  2. Asymptomatic t2 2nd degree narrow qrs
  3. Asymptomatic t2 2nd degree within or below His on EPS
  4. first or second degree av block with symptoms
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37
Q

Class IIb pacemaker indications in av block

A
  1. Av block with use of drugs but expect block to recur despite discontinuation
  2. Neuromuscular disease
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38
Q

Class III pacemaker indications in av block

A
  1. Asymptomatic 1st degree
  2. Type 1 2nd degree at av level
  3. Expected to resolve (lyme, drug)
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39
Q

Class I pacemaker indications in ami

A
  1. Persistent and symptomatic 2nd/3rd degree block
  2. Transient 2nd/3rd degree block infranodal with associated bundle branch block (if site uncertain may require electrophysiologic studies)
  3. Persistent second degree with bilateral bundle branch block or 3rd degree within or below the his
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40
Q

Class IIb pacemaker indications in ami

A
  1. Persistent 2nd/3rd degree av block at av node level
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41
Q

Class III pacemaker indications in ami

A
  1. Transient av block without ivcd
  2. Transient av block with isolated left anterior fascicular block
  3. Acquired left anterior fascicular block without av block
  4. Persistent first degree av block in the presence of bundle branch block which is old or age indeterminate
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42
Q

Class I pacemaker indications in trifascicular/bifascicular blocks

A
  1. Intermittent 3rd degree av block
  2. T2 2nd degree av block
  3. Alternating bundle branch block
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43
Q

Class IIa pacemaker indications in trifascicular/bifascicular blocks

A
  1. Syncope not demonstrated due to the block but other cause excluded
  2. Prolomged hv interval >100ms on electrophysiologic studies in asymptomatic
  3. Pacing induced infra his bloch which is not physiologic on electrophys studies
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44
Q

Class IIb pacemaker indications in trifascicular/bifascicular blocks

A
  1. Neuromuscular disease
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45
Q

Class III pacemaker indications in trifascicular/bifascicular blocks

A
  1. Fascicular but no av nor symptoms

2. Fascicular with 1st degree av block and no symptoms

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46
Q
  • Most common supraventricular tachycardia
  • Most common sustained arrhythmia in older adults
  • Most common paroxysmal sustained tachycardia in young healthy adults
A
  • Most common supraventricular tachycardia : Sinus tachycardia
  • Most common sustained arrhythmia in older adults: atrial fibrillation
  • Most common paroxysmal sustained tachycardia in young healthy adults: AVNRT
47
Q

Svt with 1:1 conduction, p wave relationships

A
  1. Avnrt: no discernible, synchronous with qrs

2. Ort (orthodromic av reentry): p waves following the qrs; rp pr interval

48
Q

Svt response to av nodal blockade

A
  1. Avnrt: terminate
  2. Ort: terminate
  3. At: continuation/terminate
  4. Aflutter: exposes underlying flutter waves
49
Q

Postural orthostatic hypotension syndrome

A
  • increase hf by >30bpm or >120bpm within 10 minutes of standing but no hypotension
  • if due to viral illness autonomic dysfunction returns to normal in 3-12 mos
  • tx: volume expansion, salt, compression stockings, fludrocortisone, midodrine
50
Q

Focal atrial tachycardia not dependent on av nodal conduction, will not terminate/change its rate with av block
Vs avnrt/avrt - node dependent

A

Tx: adenosine - higher doses maybe needed (triggered activity)
Cardioversion (if recurs suggests automaticity)
Correct precipitants
Beta blocker or calcium channel blockers
Catheter ablation

51
Q

FAT distinguished from sinus tachycardia because impulse originates elsewhere, p wave morphology different
Abrupt onset and offset

A
  • origins: crista terminalis, valve annuli, atrial septum, atrial muscle, cardiac thoracic veins (coronary sinus, svc, pulmo veins)
    1. Atrial septum: narrower
    2. Left atrium: monophasic positive p wave in lead v1 and negative p waves in I and avl
    3. Superiorly (svc, pulmo veins): + p in II, III, AVF
    4. Inferiorly (coronary sinus/ostia): - p in II, III, AVF
52
Q

Most common location of accessory pathways

A
  • left atrium and left ventricular free wall
    Followed by posteroseptal, right free wall, anteroseptal
    -Right: lbbb pattern
  • left: rbbb pattern
53
Q

Accessory pathways

A
  • wpw syndrome: atrioventricular, kent bundle
  • mahaim fibers: atriofascicular
  • lown ganong levigne syndrome: bundle of james: atria to bundle of his
54
Q

Most common tachycardia caused by an accessory pathway

A

Orthodromic av reentry tachycardia

55
Q

Nearly incessant tachycardia due to reentry facilitated by slow ap conduction

A

Permanent junctional reciprocating tachycardia

56
Q

Preexcited tachycardia

A

Ventricles activated by anterograde pathway. Most common antidromic av reentry. Wide qrs.

57
Q

Bystander ap conduction

A

Preexcited tachycardia which occurs with ap allows antegrade conduction of afib, flutter, avnrt

58
Q

Treatment of preexcited af and ci

A

CI - Amiodarone, adenosine, beta blockers, CCB (verapamil, diltiazem)
Tx - cardioversion, iv PROCAINAMIDE/IBUTILIDE

59
Q

Risk of cardiac arrest in accessory pathway with symptoms

A

2/1000 patients

60
Q

Risk of cardiac arrest in accessory pathway with no symptoms

A

1/1000 patients years

61
Q

Treatment for concealed ap/low risk ap with orthodromic av reentry

A

Beta blocker, verapamil, diltiazem, flecainide

62
Q

Treatment for very irregular wide complex tachycardia

A

Likely preexcited af or flutter: cardioversion, iv procainamide/ibutilide

63
Q

Treatment stable paroxysmal svt

A

Vagal maneuvers/iv adenosine/iv verapamil/diltiazem -> AV nodal blocking agent + iv procainamide/ibutilide or cardioversion

64
Q

Common/typical ra flutter

A
  • cavotricuspid isthmus (sub eustachian) dependent
  • counterclockwise: negative p in II, III, AVF, Positive p in V1
  • clockwise: opposite
  • 240-300 atrial beats/min, 2:1 conduction, 150bpm ventricles
  • flutter waves revealed by maneuvers which increase av nodal block
65
Q

Atypical ra flutter

A

Not dependent on cavotricuspid isthmus

66
Q

Atrial flutter tx

A
  • catheter ablation of cavotricuspid isthmus effective >90%
  • anticoagulation: same risk for embo as af
  • antiarrhythmic: amio, sotalol, dofetilide, disopyramide
67
Q

% of avnrt which converts to af in 5 yrs

A

50%

68
Q

Warfarin target inr 2-3:
Risk of major bleeding per yr
Risk of intracranial bleeding per yr

A

Warfarin target inr 2-3
Risk of major bleeding per yr 1%
Risk of intracranial bleeding per yr 0.1-0.6%

69
Q

Multifocal atrial tachycardia

A

3 diff p wave morph
100-150bpm
Tx: treat underlying (pulmo ds), amiodarone
**cardioversion not effective

70
Q

Atrial fibrillation prevalance in older than 80

A
  • 10%

More common in men

71
Q

Risk of stroke with af

A

5 fold

Cause 25%of strokes overall

72
Q

Types of af and causes

A
  1. Paroxysmal af (<7d) - ectopic foci (commonly pulmo veins)
  2. Persistenr af (>7d) - electrophysiologic remodelling
  3. Permanent af (>1yr) - chronic substrate fibrosis
73
Q

Tachycardia associated cardiomyopathy is reversible

A

Tachycardia associated cardiomyopathy is reversible

74
Q

Drug used in unstable af to reduce energy requirement for defibrillation

A
  • ibutilide: c/i - long qt or severe lv dysfunction at risk for torsades des pointes
  • baseline need 200kj synchronized cardioversion
75
Q

Duration for anticoagulation for af

A
  • <48hrs: may cardiovert
  • > 48hrs: 3wks prior to cardiovert then at least 4 weeks post cardioversion to allow for tome for recovery of atrial mechanical fxn
    • consider indefinite extention if high chads vasc
76
Q

Major source of af thrombus

A

Left atrial apoendage

77
Q

Af goal of rate control

A

Acute: Hr <100bpm
Chronic at rest: Hr <80
Chronic with exertion: hr <100bpm but may increase to 110bpm if asymptomatic

78
Q

Warfarin reduction of stroke

A
  • 64% vs placebo

- 37% vs antiplatelet

79
Q

Risk of stroke persistent = paroxysmal af
Anticoagulation required for paroxysmal af: ms, hocm, previous hx of stroke
Warfarin required if ms/rhd/mechanical valves

A

Risk of stroke persistent = paroxysmal af
Anticoagulation required for paroxysmal af: ms, hocm, previous hx of stroke
Warfarin required if ms/rhd/mechanical valves

80
Q

Valvular af definition

A

With mitral stenodid

81
Q

Factor xa inhibitor reversal agent

A

Andexanet

Ciraparantag

82
Q

Af tx

A

Rate control: beta blocker/ccb/digoxin
Rhythm control: class 1 (flecainide, propafenone, disopyramide) and class 3 (amiodarone - 3% torsades, dofetilide)
Anticoagulation

83
Q

Ventricular tachycardia nomenclature

A

Vtach - 3 pvc >100bpm
Idioventricular rhythm - 3 pvc <100bpm
Nonsustained vtach - terminate within 30s
Sustained vtach - persists >30s

84
Q

Sinusoidal vts causes

A
  • HYPERkalemia, drugs which block the na channel, ischemia
85
Q

Most frequent site of origin of idiopathic ventricular arrhythmia

A

Rv outflow tract

86
Q

Treatment of idiopathic pvc and nonsustained vt

A 
Asymptomatic + no structural heart disease
- no tx
- avoid stimulants
- beta blockers, ccb
Acute coronary syndrome
- harbinger of sustained vt and vfib
- amiodarone: reduce suddentl death but does not increase mortality
- beta blocker: reduce sudden death
- icd
87
Q

Icd indications acs

A
  • survivors if mi >40d and lvef <30%
  • lvef <35% with hf nyha II/III
  • survivors >5d, lvef <30% and inducible vt/vf om eps
88
Q

Nonsustained vt in hf tx

A
  • markers of disease severity
  • tx: class I antiarrhythmics c/i (proarrhythmics, negative inotropy, increase mortality)
    Amiodarone: decrease sudden death but no effect on mortality
    Icd: decrease mortality 36% -> 29% over 5yrs
89
Q

Pvc induced ventricular dysfunction most common source and tx

A
  • lv outflow tract or papillary muscles

- tx: amiodarone, catheter ablation

90
Q

Differentials for uniform wide complex qrs tachycardia

A
  • monomorphic ventricular tachycardia
  • svt with bbb aberrant conduction
  • svt with accessory pathway
  • rapid cardiac pacing pacemaker
91
Q

Criteria for vtach

A
  • av dissociation
  • monophasic r or rs in avr
  • concordance from v1-v6 of monophasic r or s wave
92
Q

Vtach management

A
  • acute: acls - stable trial of adenosine, amiodarone (DOC)
  • recurs: antiarrhythmic or icd
  • *more commonly, occurs as isolated episode
93
Q

Sustained monomorphic vtach associated specific diseases

A
  • coronary artery disease
  • nonischemic dilated cardiomyopathy
  • Arrhythmogenic right ventricular cardiomyopathy
  • tof repair
  • idiopathic
94
Q

Cad in monomorphic vt

  • scars from previous mi
  • 70% risk of recurremce over 2yrs
  • tx: icd (reduce annual mortality 12.3 to 8.8% and lower arrhythmic deaths by 50%), amiodarone if not a candidate
A

Cad

  • scars from previous mi
  • 70% risk of recurremce over 2yrs
  • tx: icd (reduce annual mortality 12.3 to 8.8% and lower arrhythmic deaths by 50%), amiodarone if not a candidate
95
Q

Arvc in monomorphic vt ecg findings and treatment

A
  • t wave inversion v1-v3 and epsilon wave (s wave slurring)

- icd + beta blocker (if exercise triggered)/amiodarone/sotalol

96
Q

Cardiocutaneous syndromes with arvc

A
  • desmosomal protein mutation, ad inheritance; but in cardiocutaneous syndrome, ar inheritance
  • naxos disease
  • carvajal syndrome
97
Q

Risk factors for vt risk in tof repair

A
  • repair after 5 y/o
  • high grade vemtricular ectopy
  • inducible vt in eps
  • abnormal hemodynamics
  • sinus rhythm qrs >180ms
98
Q

Idiopathic monomorphic vtach tx

A

sudden death is rare
treatment if with symptoms or lv dysfunction
- bb, ccb, catheter ablation if meds not effective

99
Q

Polymorphic vtach in mi greatest risk during

A
  • 1st hr
    Occurs in 10% of mi
    **within 48hrs of mi = does not increase risk for subsequent arrhythmia
100
Q

Polymorphic vtach mi tx

A

Acute - acls

Chronic - determined by lvef (<0.35)

101
Q

Acquired long qt characteristic initial sequence for polymorphic vtach

A

Pause dependent: pvc -> sinus pause -> prolonged qt ecg complex -> pvc which interrupts the t wave is the first beat of the polymorphic vtach

102
Q

Acquired long qt polymorphic vtach treatment

A
  • mgso4 1-2mg
  • isoproterenol infusion of cardiac pacing to increase hr 100-120bpm
  • correct underlying (hypokalemia, hypocalcemia, bradycardia, drugs)
103
Q

Congenital long qt types which account for 90% of congenital lqts

A

Type I - kcnq1 gene, trigger exertion and swimming
Type II - kcnh2 gene, trigger auditory and emotional
Type III - scn5a gene, trigger sleep

104
Q

Congenital lqts tx

A

Lqts 1/2: nonselective betablocker (preferred propanolol and nadolol)
High risk: icds
- female, qt >0.5s, syncope/cardiac arrest, recurrent symptoms despite bb

105
Q

Short qt definition, associated channel dysfunction and associated arrythmia

A
  • <0.36
  • gain of function k channel
  • af, polymorphic vtach, sudden death
106
Q

Brugada syndrome types

A

Type 1: coved
- >0.2 mV ST segment elevation, t wave inversion
Type 2: saddle
- >0.2 mV ST segment elevation, isoelectric st segment, t wave upright
Type 3: neither 1 or 2
- give ajmaline, procainamide, flecainide to reveal st elevation

107
Q

Brugada syndrome tx and channel dysfxn

A
  • hcn5a (na channel)
  • provoked by febrile illness
  • tx: QUINIDINE, catheter ablation, icd
108
Q

Catecholaminergic polymorphic vtach mutation, ecg findings, tx

A
  • cardiac ryanodine receptor, calsequestrin
  • bidirectional vtach: alternating qrs morphology
  • tx: bb, flecainide, verapamil, icd, left ventricular sympathetic denervation
109
Q

Most common inherited genetic cardiovascular disorder

A

Hocm - 1/500

110
Q

Hocm tx

A
  • bb, verapamil, disopyramide
  • icd
  • surgical myomectomy:1% risk of scd/yr
  • ethanol septal ablation: 1-5% risk of scd/yr
111
Q

Electrical storm and incessant vt definition

A
  • electrical storm: 3 or more vt/vf in 24hrs

- incessant vt: recurrence after conversion to sinus

112
Q

Treatment Electrical storm and incessant vt

A
  • correct underlying
  • torsades des pointes: mgso4
  • possible brugada: quinidine/isoproterenol
  • not working: general anesthesia, left stellate ganglion block, thoracial spinal epidural, hook to mech vent, icd
113
Q

Icd shock management

A
  • check if shock was appropriately delivered for arrhythmia
  • workup for ischemia, infection, decline in cardiac function
  • consider antiarrhythmics: amiodarone, sotalol, beta blocker, amio+ bb(more effective)
  • catheter ablation

Harrisons Cardio Part 2 (4 decks)

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